Fees/Payment: $110.00 per 55 minute therapy session (individuals, couples or family). $60.00 per 1.5 hour group therapy. Cash or check payment is due at the time of each session. Credit card payments can be made online only using Paypal (an additional Paypal processing fee of $4 per $110 must be added). For your convenience, a “Make a Payment” link to Paypal is set up on my web page: www.BoulderTherapist.com. Therapeutic phone calls longer than ten minutes, consultations and other auxiliary services requested will be prorated accordingly. Additional traveling fees may be charged for out of office visits. A late payment fee of 1.75% interest compounded monthly will be added to balances remaining unpaid after 30 days. Collection procedures may be initiated after a 60-day period where no attempt or agreement is made to pay off balance otherwise. Any exceptions to the policy above must be discussed and agreed to beforehand.

Cancellations/Missed Appointments: 24-hour notice is required to cancel or reschedule appointments without penalty. Exceptions made only for emergency circumstances (ex.: Hazardous driving conditions, severe or contagious illness, etc.). MISSED APPOINTMENTS ARE CHARGED AT THE FULL SESSION RATE. APPOINTMENTS CANCELLED OR RESCHEDULED WITHIN 24 HOURS ARE BILLED AT $65.00.

Billing/Insurance: YOU ARE RESPONSIBLE FOR PAYMENT IN FULL, REGARDLESS OF YOUR INSURANCE COVERAGE OR CLAIM STATUS. A billing statement will be made available to you and will contain all pertinent information required by your insurance company for reimbursement. Please file your own insurance claim by attaching and mailing my statement with your insurance claim form. Co-payments are accepted only after insurance claims have been processed or benefits verified. You must sign the “assignments of benefits to provider” section if you arrange to only pay the co-payment. While I may be listed as a preferred provider for your network, it’s recommended that you call to verify your coverage and/or request pre-authorization to ensure receiving benefits. Billing for your diagnosis or treatment may not necessarily be accepted by your insurance plan. Some plans require special billing attention and handling. Please check with me if you have questions. I’ll do my best to assist you, where ever possible.

Communication: My confidential phone voice mail will take your message if I am with another client or otherwise unavailable. I generally check messages throughout the day, in the evening and during the weekends, but I may not be able to return your call immediately. I DO NOT PROVIDE ON CALL CRISIS INTERVENTION. When I am out of town, my phone message will direct you to a colleague for clinical consultation during my absence. You may also e-mail me for brief communications or scheduling inquiries. however, COMMUNICATING BY E-MAIL IS NEVER SECURE AND MAY BREACH CONFIDENTIALITY MANDATES. I usually read my e-mail on a daily basis, but will respond to phone messages more reliably.Termination of Therapy: You may discontinue therapy at any time. If you decide to change our plan for meeting, please discuss this with me before quitting. I also reserve the right to discontinue meeting with you if you do not keep agreements with me, including your financial responsibilities.

Grievances: Sexual intimacy between a client and therapist is never appropriate and is a felony in Colorado. The Colorado Department of Regulatory Agencies regulates the practice of psychotherapy by licensed, certified and unlicensed practitioners. Questions or complaints can be addressed to: The Social Work Licensing Board, 1560 Broadway, Suite 1350, Denver CO 80202 (303) 894-7766.I have read the above information and understand my rights as a client. I agree to the terms as stated above or as modified below. I understand that I may be responsible for any added expenses including court or attorney’s fees if I do not follow the terms of this contract.

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